Basic Information
| Provider Information | |||||||||
| NPI: | 1104301381 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROCKWAY | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1853 FERNWOOD DR | ||||||||
| Address2: | |||||||||
| City: | WEST DEPTFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080965751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562362214 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 HADDON AVE | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081033101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567573500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2018 | ||||||||
| LastUpdateDate: | 10/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 26NJ00864200 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.